基于阳性淋巴结数的进展期胆囊癌患者生存列线图预测模型

Survival prognostic nomogram model based on the number of positive lymph nodes for patients with advanced gallbladder cancer

目的探讨进展期胆囊癌根治性切除术后阳性淋巴结数在患者预后中的预测价值,构建生存列线图预测模型。方法回顾性分析2008年1月至2013年12月西安交通大学第一附属医院收治的158例进展期胆囊癌根治性切除患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男44例,女114例;平均年龄(61±11)岁。生存分析采用Kaplan-Meier生存曲线和Log-rank检验,采用Cox多因素分析筛选患者预后的影响因素,并建立术后预后列线图预测模型,采用一致性指数(C指数)评价模型。结果 46.8%(74/158)患者出现淋巴转移,清扫淋巴结数中位数为6.5(1.0～22.0)个,阳性淋巴结数为1.5(0～12.0)个,淋巴结阳性率为25%(0～100%)。患者中位生存时间为29.0个月,1、3、5年累积生存率分别为62.0%、47.4%、42.8%。多因素分析显示T分期、切缘、病理分级及阳性淋巴结数为患者预后的独立影响因素(RR=2.446,2.694,1.897,2.892;P<0.05)。根据4个独立影响因素建立生存列线图预测模型,3、5年模型的C指数分别为0.797及0.794。结论阳性淋巴结数可应用于进展期胆囊癌患者的淋巴状态评估,指导患者生存预后分析。基于T分期、切缘、病理分级及阳性淋巴结数建立的列线图模型有助于对患者生存进行个体化预测。

Objective To explore the prognostic value of positive lymph node metastasis number in patients with advanced gallbladder cancer after radical resection and to establish a survival nomogram model for prediction. Methods Clinical data of 158 patients with advanced gallbladder cancer who underwent radical resection in the First Affiliated Hospital of Xi＇an Jiaotong University from January 2008 to December 2013 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. There were 44 males and 114 females, with an average age of （61±11） years. Survival analysis was performed using Kaplan-Meier survival curve and Log-rank test. The factors influencing the patients＇ prognosis were screened by Cox multivariate analysis. A nomogram model for the postoperative prognosis was established and was evaluated by consistency index （C-index）. Results Lymph node metastasis was observed in 46.8%（74/158） of the patients. The median number of dissected lymph nodes was 6.5（1.0-22.0）. There were 1.5（0-12.0） positive lymph nodes with a positive rate 25%（0-100%）. The median survival time was 29.0 months. The 1-, 3-, 5-year accumulate survival rate was 62.0%, 47.4% and 42.8%, respectively. Multivariate analysis showed that the independent factors influencing the patients＇ prognosis were T staging, incisal margin, pathological grading and number of positive lymph nodes （RR=2.446, 2.694, 1.897, 2.892; P〈0.05）. A nomogram model for survival prediction was established based on the 4 independent factors, and the 3- and 5-year C-index was 0.797 and 0.794, respectively. Conclusions It can be used to evaluate the lymphatic status of patients with advanced gallbladder cancer and to assist the analysis of patient＇s survival through observing the positive lymph node metastasis. The survival nomogram model based on T staging, incisal margin, pathological grading and number of positive lymph node metastasis can help to make an individualized survival prediction for the patients.